Objective: To describe the clinical features of tremor associated with thalamic infarcts and its treatment with thalamic Deep Brain Stimulation (DBS).

Background: Delayed onset involuntary movements after thalamic stroke are well described. These are associated with dystonia-athetosis-chorea-action tremor with ataxia. These deficits are thought to result from lateral posterior thalamic strokes that damage the leminiscal sensory pathways, the cerebellar rubrothalamic tract and the pyramidal tracts. DBS is an established effective treatment for various tremors. However, the role of DBS for this particular tremor is less clear.

Methods: We present the case of a 62 year old female with a disabling bilateral arm and head tremor. She had initially presented with dissociated sensory loss and pain in her arms due to syringomyelia; treated in 1994 by foramen magnum decompression and a VP shunt. The decompression was revised in 1998 because of progressive weakness and enlargement of the syrinx. This was complicated with bilateral ventral posterior thalamic infarcts causing profound quadraparesis and sensory loss in the upper limbs, which gradually improved. 4 years later she developed a complex tremulous movement disorder of the arms. The tremor was present at rest, on posture and on movement and was severely intrusive. It was associated with dystonic posturing of the hands and pseudoathetosis of the fingers with reduced joint position sense up to PIP joints. Arm movements were ataxic and tendem gait was impaired.

Bilateral thalamic Vim DBS was performed to improve arm function. Multiple DBS adjustment were undertaken to ameliorate the tremor. The final stimulation was set at double monopolar on one side and wide bipolar on the other.

Results: This patient had suffered severe complications of bilateral ventral posterior thalamic infarcts, including a complex cerebellar tremor associated with sensory deficit, mild weakness and ataxia. She had good suppression of her tremor with DBS, resulting in significant functional gain despite the sensory deficit. The patient was able to use her arms for fine tasks having been severely disabled for years.

Conclusions: Ventral-posterior thalamic infarct associated tremor can be successfully supressed with VIM thalamic DBS; functional gain can be achieved provided the associated sensory loss is not severe.

References:

1. Kim JS. Delayed Onset mixed involuntary movements after thalamic stroke. Brain. 2001; 124(2): 299-309.
2. Benabid A L, Pollac P, Hoffman D et al. Long Term Suppression of Tremor by Chronic Stimulation of the Ventral Intermediate Thalamic Nucleus. The Lancet. 1991;337 (8738): 403-406.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/successful-deep-brain-stimulation-treatment-of-incapacitating-tremor-resulting-from-bilateral-thalamic-infarcts-complicating-surgery-for-arnold-chiari-malformationsyringomyelia/